"Breathing" Archives
Posted 04/09/2012
Spring has come (and gone?) to Lincoln, NE and with that comes sporting events. Our oldest son, who is in Kindergarten, just started recreational soccer and I have volunteered to be the coach of his micro league soccer team. It’s great fun and I don’t know who is having more fun, the kids or myself. Micro soccer is basically 4 on 4 soccer with small goals and no goalie to give the kids all a chance to kick the ball and have fun. And it works. The kids all get involved and a chance to contribute and play and I think it is great. Back when I was younger I played soccer and even coached my younger brother’s teams when I was in high school so I don’t feel too lost… older but not too lost. If you have ever watched kindergarteners play soccer you will appreciate the game play as basically a mad, chaotic rush or amoeba-like conglomeration of 8 kids swarming after one ball until it finally gets kicked free and then they all run after it. This continues back and forth until either the ball goes out of bounds or into one of the goals. Usually if one kid gets free with the ball he can outrun everyone else and score an easy goal. At our first practice I gathered the kids in and asked them if they wanted to know the secret to scoring lots of goals in micro soccer. Of course since it was a secret they all desperately wanted to know. The secret is for all of the players to stay in their position and wait for the ball to get passed to them. Since the other team’s 4-headed amoeba will be chasing the ball, as soon as the ball comes loose our players should have a nice easy pass to an open teammate or path to the goal to score. If we keep one player to stay back and be defense if the other team should get loose there is always someone to be in the way to keep them from scoring. Easier said than done of course. It isn’t easy to get 5 and 6-year olds to do this, or just to refrain from grabbing the ball with their hands every time it comes to them for that matter, but it is a great goal to have. Of course the main goal is for everyone to play and have fun, but if we can keep everyone in the right position they will have a much better chance for scoring goals.
Every day with our patients here at the Hruska Clinic we are constantly trying to get our patients to get their muscles into the right position so they can be effective at doing their jobs which in turn allows our bodies successful at doing their jobs. This can be anything as simple as breathing properly or as complicated as playing volleyball or soccer. This focus on first making sure muscles are in the right position before progressing with a rehab program is one of the main things that makes our clinic different and successful. If any muscle is in the wrong position it will never be able to be as strong or effective as if it was in the right position. For example let’s look at the muscles that we use to squeeze our hand into a fist. If you bend your wrist back as far as you can and then try to make a fist and squeeze as hard as you can you will find your grip strength is fairly poor. Then bend your wrist all the way forward and try to make a fist. Even worse… you probably can’t even get your fingers to touch your palm. There is a certain position of your wrist that optimizes the strength of the muscles that give you grip strength. Occupational therapists that manufacture splints can tell you probably the exact specific angle or degree of what that position is to optimize grip function. It doesn’t matter how much or how long you try to strengthen your grip muscles if you do it in an improper position. Your grip will never get as strong as it could just by putting your wrist in the proper position. This holds true for every muscle in your body which is why we feel so strongly about making sure your body is in a neutral or optimal position for muscles to function the way they should. Just getting into a good position will have more benefit and results than months of training in a wrong position. We will seek to find whatever it takes to put your muscles in the proper position, whether that is using specific exercises, manual techniques, foot orthotics, intra-oral appliances, braces, glasses, or duct tape and chicken wire if it works (just kidding). We will do this because we know that if we don’t the rest of our program will ultimately not have the success we want. In my next blog I plan to describe some specific muscles that here at the clinic we are constantly challenged to get into the right position to function properly and how we might address that with our programs.
After 2 soccer practices and games we seem to have the defensive position figured out and already the kids saw what a difference that makes. My next goal is to get the other positions figured out and then… look out YMCA Kindergarten boys Micro Soccer league… we’ll be unbeatable. Ha! Wish me luck!
Comments or questions? Let me know…
Posted 04/04/2012
What is a tilted pelvis? A pelvic tilt is actually a fairly common postural problem. A pelvic tilt occurs when the pelvis tilts in one direction. There is an anterior pelvic tilt in which the pelvis tilts towards the front of the body and there is a posterior pelvic tilt in which the pelvis tilts towards the back of the body. The anterior pelvic tilt is generally the most common. Pelvic tilts are owed to muscle imbalances. In other words, certain muscles may not be working properly and other muscles may be working too much. Structurally, an anterior pelvic tilt can cause some muscles to become tight and others to be lengthened.
The back muscles and hip flexors become shortened in length when the body has an anterior pelvic tilt. Furthermore, when the back muscles and hip flexors shorten, the abdominal and hamstring muscles become lengthened. A common misconception is that the hamstrings appear to be short and tight and need to be stretched. On the contrary, the hamstrings are actually lengthened and tense secondary to the pelvis falling forward and need to be activated to return the pelvis to a more neutral position. Often times patients with low back pain are often told to stretch their hamstrings to relieve their discomfort. In response to stretching of the hamstrings, the pelvis may tilt even further forward and the lower back muscles may become tighter to keep the body upright.
Today I looked at the anterior pelvic tilt and how this position may affect your body. An anterior pelvic tilt can not only be an impairment to your posture but it can place undue stress on muscles, joints and your breathing to name a few. Your problems may range from a constant achy lower back to countless debilitating symptoms throughout your body. With a few exercises from a PRI therapist you can help correct your tilt and have a more balanced pelvis.
Questions or thoughts on this blog? Leave a comment!!
Posted 01/20/2012
As you may or may not know I am a fairly recent transplant here to Lincoln. I grew up in Colorado Springs, CO. Obviously here Big Red football dominates but as I was growing up John Elway and the Denver Broncos was where we invested our loyalties. I still have to root for the Broncos and this year has been fun. Whatever your opinions of their quarterback Tim Tebow are, he has been the big story in Denver and throughout the NFL. A new word has entered our culture because of Tim. Tebowing. It is the act of getting down on one knee and praying, usually with head bowed on a hand or fist as Tim frequently does on the football field. It is now an internet craze where people will have their picture taken in that position in random locations. Google Tebowing for some fun pictures.
Recently, I have come up with a word for an activity that we like to do in the clinic with our exercises. Smunching. Or smunch for short. I looked it up online to see if it has other meanings and apparently it is used by a group in Phoenix to describe eating a Saturday morning brunch. So I guess I can’t trademark it. I like it though. Smunching. It just rolls off the tongue. To me it is part smush and part crunch and describes a movement where you bend your trunk sideways bringing your ribs down toward your pelvis. As therapists we call it side-bending or thoracic abduction. It requires a contraction of your lateral abdominal oblique muscles and is something we encourage on the left side with PRI exercises. Left lateral abdominal muscles (including internal obliques and the transverse abdominis) are very important, wonderful, and yet too often underused muscles that can make or break someone’s success or recovery with a PRI program. They are the next muscle that I want you to be able to feel. Can you feel it? Smunch. How about now.
It is not exactly news that abdominal muscles are important for “core stability” or back stability. What is often missed in traditional exercise or rehab programs is the need to address and correct differences in the position, function and use of muscles on the right and left side. Our philosophy here at the Hruska Clinic identifies and describes a normal, asymmetrical pattern of function. If you have not read much about that I recommend reading some of our other blogs here or on the Postural Restoration Institute website. This pattern describes a tendency to stand and shift our weight more on our stronger, dominant, stable right leg than our left leading to a tendency for the pelvis to drop forward on the left and orient or point to the right. Imagine if there were headlights on the front of your hip bones. In this pattern our headlights tend to point more into the ditch than into oncoming traffic. However, in order to reach with our more dominant right arm and look at oncoming traffic with our eyes we will rotate our upper body back to the left to compensate. When this pattern becomes too active or strong we can run into trouble.
The last 2 blogs I have done described using the left inner thigh and left glute med to line the pelvis back up and get our headlights pointing straight ahead. Unfortunately what has happened above the pelvis in that pattern (the need to always rotate the spine left) has had some impact on function above the pelvis and needs to be addressed. As our spines rotate to the left to reach with our right hand to drive our car, or use the mouse of our computer, or realign our bodies with the direction we want to walk, the rib cage rotates into a position where the right ribs come down toward the pelvis and are anchored with right abdominals, while the left ribs are rotating up and away from the pelvis. The left abdominals are not working and being lengthened which decreases their advantage to work even if we wanted them to. These left abdominal muscles then become weak in their ability to do several important things for us. They lose their ability to stabilize the pelvis on the left side so it won’t drop more forward. They lose their ability to laterally bend the trunk to the left (smunching to the left if you are paying attention). And probably most importantly they lose the ability to pull the left lower rib cage down and stabilize it so the left diaphragm muscle has an advantage to contract and pull air efficiently into your lungs (maximize the ZOA on the left side for you therapists). The left abdominal obliques, and the ability to smunch or get into thoracic abduction to the left, is of utmost importance to make sure the hard work your left inner thigh and left glutes are doing for your pelvis continues to work, as well as to help correct the compensation your upper body has had to do because of the normal positional shift of the pelvis to the right. The abdominals are what is going to integrate or coordinate what your lower body and upper body are doing so they can work together to do things like walk, and run, and go up and down stairs, and breathe, or do any reciprocal activity without excess strain or falling back into old patterns. In our normal pattern the right ribs and muscles are already smunching so we need to really emphasize the left side to create a functional balance.
Many of our exercises emphasize smunching on the left side by either reaching the left hand down towards your feet, arching the left side up when lying on the left, or even passively just positioning you to bend your trunk to the left. You should be able to feel it. But what if you can’t. Probably the most common reason for not being able to feel it in any position is a tendency to use your left back extensor as the muscle to smunch. It will bend your spine to the left but will also extend your back. If you are smunching and you feel your back make sure you round your back a little more and keep it rounded as you smunch. As we talked about earlier the abdominal muscles pull your ribs down which is what happens when you exhale or breathe out. If you hold your breath or are in a state of inhalation your abdominal muscles will have a harder time contracting so another trick is to fully exhale and feel your ribs go down. We will even use balloons or straws to resist the exhalation to feel the abs work. The key is then to try and maintain that feeling as you use your diaphragm to breathe in. If you lose your smunch when you breathe in we are never going to get anywhere. Sometimes when lying on your left side it can help to roll up a towel and put it under your left side to give yourself a feeling of where to smunch. In standing or squatting if you let your back extend and your pelvis drop forward you will stop feeling your abs and the back will take over. Think about reaching your knees forward as you squat to keep the pelvis tucked and abs on.
I can only hope that smunching (to the left) will become as much a craze as Tebowing has. But until we get a polarizing athlete to do more smunching I think Tim will have a definite edge. I personally am still going to try and see if we can make it a craze one patient at a time. If you all get creative feel free to send or post some smunching pictures and maybe we can start this craze and help people all at the same time!
Smunching for exercise…
Smunching while reading…
Smunch-bowing???
Questions for Torin? to send him an email. Or write your comment below!
Posted 01/12/2012
The saying “squared away” means that one is in an adequate position for whatever has to be done next. This saying has nothing to do with something actually being squared in shape or form. It means: everything is in order; everything is arranged/ positioned and taken care of. On the other hand, when you look at the human body, you can shape it by creating or arranging it to determine its form. Postural Restoration Institute® concepts/principles are governed by posture, position and patterns. In every moment we are shaping our bodies into a posture that corresponds to the demands placed upon it. Something that arranges and repeats itself in a predictable way is a pattern. The body is shaped by how we use it and patterns govern how we function. We all fall into patterns which create postures that reflect our body’s overall shape and/or position.
Geometry is a term concerned with the study of basic shapes. Shapes are used to suggest meaning and organization. It’s sometime easier to picture the human body as an arrangement of geometric shapes. The body’s shape affects the body’s posture, position and patterns. A trapezoid and a square are two common shapes. In this blog I will illustrate how the body grows more accustomed to the shape of a trapezoid and, by implementing Postural Restoration Institute® concepts we can reshape it into a square. It is this shape-changing ability that is most relevant to breathing, because without this movement, the body cannot breathe at all. To understand how the diaphragm causes this shape change, I will examine its shape and location in the body, where it’s attached, and what is attached to it, as well as its action and relationship to the other muscles of breathing. This geometrical relationship is important to recognize, not only to distinguish the body’s overall shape, but for another reason: so that we can understand how the body functions in regards to its overall position! Successful function, of course, expresses itself in a particular shape. In order to understand this relationship, we will start with the basic anatomy, function, and mechanics.
For starters, the pelvis is directly connected to the spine. Therefore, the position of your pelvis will affect the position of your spine and rib cage. The combination of an elevated chest (rib cage) and an anteriorly tilted pelvis is a common posture that severely compromises the capability to attain proper stabilization of the pelvis and ribcage. In an ideal world, the ribcage and the pelvis should be relatively horizontal and/or parallel to each other for efficient breathing to occur. The importance of breathing cannot be overemphasized. On average you breathe about 24,000 times per day. Postures can contribute to proper breathing as well as cause breathing restrictions you hope to eliminate. Yet how much attention are you giving to your breath as it relates to the position of your pelvis and your rib cage? As an example, the diaphragm contracts approximately 24,000 times a day and ultimately changes the position of the pelvis and rib cage with each breath. Even the smallest restriction of movement, whether it is the pelvis or the rib cage, can result in a significant consequence, as the diaphragm is stressed 24,000 times a day! Fortunately, this cumulative affect works both ways. In other words, not only can changing the position of the pelvis affect rib cage position, but likewise, rib cage position can affect pelvic position. Let’s look at some of the structural implications of the positioning of the pelvis and how it relates to the rib cage.
Let’s say the pelvis is a bowl and the bowl is full of water. A forward pelvic tilt would tilt the bowl forward spilling the water out in front; likewise, a backwards pelvic tilt would tilt the bowl back spilling the water out the back. Dysfunction in your pelvis will “spill over” and create a dysfunction in your spine. Any dysfunction in your spine will create a dysfunction in your rib cage. Therefore, a forward tilt of your pelvis would elevate the front of your ribcage; likewise a backward tilt of your pelvis would lower the front of your rib cage. (Figures 1 & 2)
Now let’s take a look at how the muscles that affect the position of your pelvis and rib cage and put it together. Remember that a muscle has at least two attachment sites. When a muscle contracts, it shortens, bringing the two attachment sites closer together. The muscles that attach to the front of the pelvis and the upper leg are called the hip flexors. When they contract they bring the leg closer to the front of the pelvis. This muscle would either lift the leg or they would tip the front of the pelvis down when they contract. Muscles that attach to the back of the pelvis and back also tip the front of the pelvis down when they contract. These paraspinal muscles can be chronically tight and your pelvis therefore could be chronically tipped forward into an anterior tilt.
The hamstrings, gluteals, and abdominal muscles work together to tilt your pelvis backwards. The hamstrings and gluteals have attachments on the pelvis and upper legs. When they contract they pull the back of the pelvis down towards the backs of the legs, while the abdominal muscles pull the front of the pelvis upwards. Ideally there should be a balance between the muscles that tilt the pelvis forward and the muscles that tilt the pelvis backwards, especially when upright.
The diaphragm interconnects your rib cage, spine, and pelvis. Because of these relationships the diaphragm is significantly influenced by posture and continuously influences breathing. When viewing from the side, the diaphragm looks like a big upside-down letter “J” that forms a floor across the lower rib cage. The diaphragm is connected in the front, along the sides of your lower ribs, and also along the front side of your spine. The intercostal muscles are the muscles between each of your ribs. There are two types of intercostals. The external intercostals are responsible for pulling the rib cage up and out during inhalation. The internal intercostals are the muscles of exhalation; they pull the ribcage down and in.
The pelvis and its direct attachment to the spine is the determining factor for the shape of the diaphragm, and must be supported by the muscles that attach to the rib cage and the pelvis. Therefore, when the rib cage changes shape, so does the diaphragm. For this reason, inhalation suggests a forward tilt of the pelvis, facilitating spinal extension and thus positioning the diaphragm more towards the shape of an upside-down letter “L”. Whereas, exhalation suggests a backward tilt of the pelvis and facilitates spinal flexion, thus positioning the diaphragm more towards the shape of an upside-down letter “J”. (Figures 3 & 4) Breathing is rhythmic. The rhythmic movement of your diaphragm is constantly changing from an upside-down letter “J” to an upside-down letter “L” with every inhalation and exhalation you take during the breathing cycle.
On inhalation, the diaphragm muscle contracts, and pulls the bottom of the lungs downward causing them to fill, while the ribs flare upwards and outward to the sides. When the external intercostals pull the rib cage upwards and outward the upside-down “J” flattens into an upside-down letter “L”. On exhalation, the internal intercostals and to some degree the abdominals pull the rib cage down and inwards restoring the diaphragm to its original position of an upside-down letter “J”.
During inhalation, the diaphragm flattens into an upside-down letter “L” as it descends and meets the resistance of the abdominal muscles and abdominal contents. The diaphragms activity depends on the position of the spine and rib cage, which forms a “fixed point”. The term “fixed point” implies which attachment site of a muscle that remains “fixed” or stationary and allows the opposite attachment site of the muscle to freely move. As with all muscles, the type of movement the diaphragm produces will depend on which end of the muscle is stable and which is mobile. If the rib cage is in the inhalation position, with the sternum and ribs elevated, the activity of the diaphragm is impaired. This particularly affects the lumbar section of the spine. Due to the diaphragm’s attachment to the front of the spine, every subsequent breath you take now pulls your pelvis into a forward tilt. Breathing is then limited to the upper rib cage, which is pulled upward by the accessory respiratory muscles of the neck.
As a result of this position, normal pelvis, rib cage, and diaphragm biomechanics are disrupted, and subsequently, the entire function of the diaphragm is altered. The back muscles use this fixed point as an opportunity to contract and further arch the spine. This fixed position of an elevated rib cage and forward tilt of the pelvis results in increased lower back tension as well as increased activity of the upper accessory respiratory muscles of the neck in attempt to get more air into the lungs. Furthermore, this prevents the diaphragms ability to return to a relaxed resting position during the exhalation phase of breathing.
Mechanical relaxation is the process by which the muscle actively returns, after contraction, to its initial length and load. The diaphragm, like every other muscle in our body, likes a proper resting length. The diaphragm contracts and relaxes continuously throughout life and must return to a relative constant resting position at the end of each inhalation-exhalation cycle. Muscles function the best when close to an ideal length (often their resting length). When muscles are stretched or shortened beyond this (whether due to the action of the muscle itself or by a sustained position or posture) the force generated by the muscle decreases.
An elevated rib cage affects respiratory musculature function by causing the muscles to operate in an undesirable position and by flattening the curvature of the diaphragm. If the rib cage remains fixed in an upward position, the diaphragm’s mechanical purpose is obviously compromised. The diaphragm does not have the length and force to allow the rib cage to move through its full range of motion required for a full breath. The diaphragm’s shape changes from an upside-down letter “J” to an upside-down letter “L” as a result of the undesirable positioned rib cage and pelvis.
Difficulty breathing usually originates from restricted movements of breathing and usually from incomplete exhalation. The muscles include the diaphragm, abdominal, and neck musculature that hold the rib cage in an elevated state. As a result, individuals exhale incompletely.
Individuals who exhale incompletely as a result of ribcage and pelvic position habitually have an expanded chest, hanging belly, high shoulders, and a shortened neck. The expanded chest results from the rib cage being in a state of inhalation due to the pelvis being forwardly tilted and the rib cage being elevated. The hanging belly comes from a diaphragm that, being always partially contracted and more towards the shape of an upside-down letter “L”, pushes the abdominal contents down and out of their normal position; the high shoulders come from contracted “shortened” neck musculature lifting the upper ribs in a chronic attempt to get more air into the lungs.
Now let’s get “squared away”! The diaphragm’s mechanical action and respiratory advantage depends on its relationship and anatomic arrangement of the pelvis as it relates to the rib cage. As stated earlier, when you inhale your rib cage elevates while the front of your pelvis tilts forward. Using the upper pelvis and lower rib cage as reference points, this inhalation position resembles the shape of a trapezoid. Likewise, as you exhale your lower rib cage is pulled down while the front of your pelvis tilts backward resembling the shape of a square. Using the Postural Restoration Institute® non-manual techniques you can guide the rib cage and diaphragm into a position where the diaphragm regains proper mechanical advantage to efficiently contract and can rest, resembling the shape of an upside-down letter “J” rather than an upside-down letter “L”. (Figures 3 & 4) The muscles often recruited to maintain the diaphragm, rib cage, and pelvis in the proper position include the abdominal obliques, hamstrings, and gluteal.
Allowing the diaphragm, rib cage, and pelvis to be literally “squared away” will allow these structures to obtain an adequate position/shape for whatever has to be done next, thus allowing normal breathing mechanics to occur. When the diaphragm, rib cage, and pelvis are positioned properly, correct breathing patterns are simplified, producing a more adequate posture. The ideal posture for diaphragmatic function occurs when the pelvis is level and the chest isn’t sticking out or elevated. This results in improved movement with greater strength, power and endurance.
Leave a comment for Jason! Or to send him an email.
Posted 12/07/2011
I typically get my blog ideas for clinical experiences, and over the past week, I had a couple patients who were having trouble with their home exercise program that I had given them. Both patients were experiencing upper back/neck tension with the exercise shown below. This exercise should relieve tension (not cause it) when performed correctly. Therefore, I further analyzed the patient’s performing this activity. In both cases, the problem was that they were not exhaling correctly. One individual was exhaling with “pursed” lips, while the other was exhaling very quick and forcefully.
Those who have been to our clinic know that breathing is important with every exercise you do! Respiration is the foundation of the science of the Postural Respiration Institute™. Exhalation is the focus of today’s topic. There are several reasons why we emphasize patient’s breathing correctly with our activities, but most importantly to appropriately using the diaphragm as a respiratory muscle rather than a postural stabilizer, to help us get into a “neutral” or flexed position, and to minimize use of accessory (neck) muscles to help breathe on the next inhalation.
I had to teach both these patients to exhale correctly, and when doing so they had no tension in their upper back or neck performing the exercise. The exhalation phase of breathing should be about three times longer than the inhalation. If one does not fully exhale all the air, then “dead air” remains in the chest wall, your ribcage remains elevated and externally rotated, and muscle tension develops in your neck and shoulders. We sometimes use a spirometer to measure the amount of air you can exhale, which is often decreased. If you never get all the air out of your body, you cannot fully inhale because space in the lungs in being occupied by the “dead air”. Not only is this important for decreasing muscle tension, but air exchange controls oxygenation of our body. When we inhale, we supply our body with oxygen, and with exhalation we eliminate carbon dioxide. If you have “dead (non-oxygenated) air” in your chest wall, you cannot fully re-oxygenate on inhalation, and you may be fatigued easily, get out of breath with simple activities such as going up a flight of stairs, get headaches, not sleep well or wake up tired after a full night of sleep.
To help these two patients over the past week, I really encouraged a full exhalation. I am often saying “Blow all the air out, every last bit drop of air that you have in your lungs.” I often utilize tools such as a straw, party favor or balloon to help the patient realize they are getting the air out, as well as provide a small amount of resistance which engages the abdominals and assists with pulling their ribcage down into a depressed and internally rotated position assisting them to get all the air out. So, please consider, have you (and/or your patients) been exhaling correctly (and fully) with PRI activities?
Questions for Jen? to send her an email! Or post a comment!
Posted 11/28/2011
Every day at the Hruska Clinic and across the country, PRI trained Physical Therapists assess and determine whether or not their patient is neutral. Neutral can be used in various contexts. I will provide you with everyday occurrences in which the word “neutral” is used and I will then use these examples of how it relates to the human body. By definition, neutral is:
- The condition of being disengaged in contests between others.
- State of taking no part on either side.
- Indifference.
- Being mutually acceptable to both sides.
All phenomena is defined in relation to its opposite. How do we understand the idea of hot without cold, forward without reverse? Hot and cold are different points on a spectrum of an understanding of what we might call “temperature”. Forward and reverse are different points on a spectrum of an understanding of what we might call “motion”. Thus things always come in pairs. Neutrality, on the other hand, lacks the bias towards one of these opposites. Automobiles have a neutral gear, you are neither moving forward nor backward. Likewise, warm suggests you are neither hot nor cold!! We are constantly seeking a balance between these opposites-they are always moving--there is never a time when they stop. Notice I didn’t say anything about resolving this balance. If there was perfect balance, there would be no motion. When these opposites are managed to obtain the best of both conditions, the conflict between these opposites is converted into symmetry. Let me reit¬erate again how important this is: it’s the constant seeking of balance between opposites that creates our lives as we know it.
We know that we cannot always be neutral in everything we do All too often we end up judging our every thought, emotion, and action as positive or negative. Some individuals have strong opinions or positions on current events or topics; some individuals are liberal where others may be conservative. Other examples that can be related to this include war, euthanasia, taxes, abortion etc. When we look around, there are many examples in which we tend to hold a strong position or bias towards something whether it is right or wrong. That’s a matter of opinion!
So where does “neutral” fit in? Considering the multiple interpretations of the word, I will go out on a limb as a PRC therapist and state “Our patients never obtain complete neutrality!” Wow! What do I mean by this? We as physical therapists are constantly trying to determine whether or not our patient is “neutral”. To truly be “neutral” would mean that the balance point would always meet in the middle; you are neither here nor there kind of thing. How often do you suppose this happens? I will pose another question; do you think our bodies are always in a position of neutrality? There are various movements and positions that we place our body in on a daily basis, we flex and extend, we adduct and abduct, we inhale and exhale. We never just stop in the middle with these movements. To move from one extreme range of motion to the other requires the presence of a mid-point or what I refer to as neutrality. Neutrality is the ability to accept a movement or position in the reflection of the other without conflict. Neutrality is a “range” and/or “zone” of movement; it is a “transitional position”. You can’t get from here to there without crossing the middle! So it comes as no surprise that good attracts bad, and bad attracts good. Likewise flexion attracts extension and adduction attracts abduction. We as humans all hold positions and/or bias whether we like to extend or flex, believe or disbelieve, and whether it is good or bad. And, to complicate matters, what is observed as “good” by some will be observed as “bad” by others. This cycle continues on and on!
In summary, I spoke with my mentor, Ron Hruska, about this topic. As we discussed this topic we both concluded that “neutrality” in its real sense is a “transitional position”. Some patients may be biased towards a particular movement or position. Whether it is right or wrong we all have tendencies towards a matter of opinion, position, or movement pattern. We as PRI therapists must accept the fact that our patients may never be able to achieve “neutrality”! It is our job to allow our patients to experience this “mid-range” and/or “zone of neutrality” and not be biased towards one extreme over the other.
I would appreciate any comments and insight regarding this matter…
Posted 11/22/2011
This past spring my wife, Leslie, and I went to Las Vegas on a little get-away trip and left our kiddos home with Grandma and Grandpa. At that time we were coming out of a long winter in North Dakota and just needed some sunshine and warmth. We spent a LOT of time at the pool soaking up the sun and relaxing. We had been there before so didn’t feel the need to walk the strip too much and it was very relaxing. The highlight of our trip, however, was getting a chance to see ‘The Lion King’ musical before it left Vegas. Yes I know, we took a vacation to Vegas, without kids, and ended up seeing The Lion King. It might sound a little pathetic but it was great. If you have never seen the musical I highly recommend it. The sets were amazing, the costumes…amazing, the singing… amazing. Of course the song we all remember from the movie was Elton John’s “Can you feel the love, tonight?” I know you all can hear it in your heads now… sorry about that.
Can you feel it? If you have come to therapy here or with a PRI trained therapist this is one question that I am sure your therapist has asked many, many times. Probably to the point that you hear your therapist ask it every time you do your exercises at home. When we are doing an activity with our patients we are trying to turn specific muscles on and turn other specific muscles off to improve the way in which we move. If you cannot feel the specific muscles we want you to feel when doing your activities, or are feeling other muscles too much, you are not going to have the success with the activities that we would like you to have. So we ask: Can you feel this?… Can you feel that?… Are you feeling this?… Can you feel the love, tonight? (Just kidding). To underscore this importance of “can you feel it,“ over the next few blogs I want to highlight a few of the major muscles we want you to feel, and probably more importantly if you are not feeling them what we may need to work on to be able to feel the correct muscle work.
Usually one of the first muscles we want our patients to feel is the left inner thigh muscle, or adductor. In our normal pattern of asymmetry our body has a tendency to center our weight, or base of support, over our right leg. This weight shift is usually accomplished with activity of the right inner thigh muscle to pull the body to the right. In order to do this our brain, primarily with reflex activity, turns off the left inner thigh muscle to make this shift easier. This in and of itself is not a bad thing as long as we have the ability to turn on our left inner thigh, turn off our right inner thigh and shift our weight to the left side as easily as we can to the right. Think about slow dancing (I’m thinking of a certain Elton John song…) and you can picture how the inner thigh muscles can pull or sway you from side to side. In order to get this side to side (frontal plane) activity to occur equally we want our patients to feel their left inner thigh work more than their right inner thigh to overcome our normal asymmetrical tendencies.
So, can you feel it? If you can, Great! Keep feeling it because we want you to use that muscle to stabilize your pelvis and not let it sneak back to the right. If you can’t then we need to address some other issues so that you can feel it. The things that might keep someone from feeling their left inner thigh work are primarily things that prevent them from being able to get in a proper position that allows them to fully shift their center of gravity to their left side and shift their pelvis over the top of their left hip bone (known as AFIR to PRI trained PTs). There may be some restrictions in the hip joint itself (posterior capsule) that need to be stretched out to allow the normal joint mechanics to occur, and allow the pelvis to shift over the thigh bone. If someone cannot fully get their hip socket into that position it will be challenging at best to feel that inner thigh muscle work. This will probably be the first thing we will address with some stretching activities for your left hip. If the right inner thigh muscle is too strong, hyper active, or tight, it may be preventing the pelvis from shifting correctly to the left or the left inner thigh muscle from turning on. If this is the case we may need to do some activities to inhibit or shut off that hyperactive right inner thigh (right adductor inhibition). Sometimes our patients can feel their inner thigh great lying down, but then when we transition to standing activity all of a sudden it is impossible to feel it. We then usually cue those people to find and feel their right shoe arch. This is done for a few reasons. If the center of gravity is too far to the right (which is part of our normal asymmetrical pattern) the tendency is to roll onto the outer aspect of the right foot which will cause you to use your right inner thigh (as opposed to the left leg) more for stability. Again if the right inner thigh is working too much it will be difficult to find and feel the left inner thigh. If we cue a push into that right arch that will allow the center of gravity to shift back to the left, shut off the right inner thigh muscle and allow better feel of the left inner thigh. Sometimes we may need even to look into footwear or orthotics to assist this to happen. One last thing that may be affecting someone’s ability to shift their weight to the left appropriately is the inability to fill up the right lateral chest wall with air. Once again our normal asymmetrical bodies and patterns create difficulties for our left diaphragm to work efficiently and for our right lateral chest wall to open up or expand the way it should (right apical expansion). If this is significantly restricted it can limit the ability to shift to the left and to feel the left inner thigh. So we may need to even look into activities that stretch the right lateral (and sometimes posterior) chest wall to get the body in a position to allow the left inner thigh to work as well as we need it.
I guess the bottom line is that if you cannot feel your left inner thigh and we keep asking and asking “Can you feel the love tonight?” let us know so we can address all of the issues that may be holding you back from progressing the way we want you to. Oh, and if you get the chance to see The Lion King I highly recommend it, and maybe, just maybe, you’ll hear your therapist’s voice saying “Can you feel it?”
Questions or comments for Torin? to send him an email.
Posted 10/05/2011
In this video, Lori discusses how devices such as the Power Lung could help your physical therapy program…
Happy Running!
Lori
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More blog entries can be found in the archives…
Posted April 9, 2012 at 11:11am by Torin Berge.
